The URL can be used to link to this page

Home My WebLink AboutApplication 501 Evergreen Way (11) TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT 1540 Sullivan Ave., South Windsor, CT 06074 Phone Number: (860)644-2511 x248, Fax Number: (860)644-7280 TEMPORARY/SPECIAL EVENT FOOD SERVICE LICENSE APPLICATION ***Must be submitted 2 weeks prior to event*** Event Name: The Promenade Shops at Evergreen Walk:The Greater Hartford Food Truck Fest Event Date(s): June 23'd and 2Vh Event Time: Sat 11AM—7PM Sun: 11AM—6PM Event Location: Evergreen Walk Park near LL Bean—The Promenade Shops at Evergreen Walk,South Windsor CT 06074 PERSON IN CHARGE INFORMATION Last Name: Gardella First: Amanda M.I.:D Date: 05/22/18 Sheet Address: 12 Cheryl Drive, Apartment/Unit#: Suite 4 City: Canton State: CT Zip: 06019 Phone: Phone 8i Cell 860-413-2281/860-387-3675 E-ail Amanda.aardella dibememct.com ORGANIZATION YOUR REPRESENT:N G (IF ANY) Representing: Cr Scoop Shops,LLC.DBA Ben&Jerry's Catering Street Address: 12 Cheryl Drive Apartment/Unit#: Suite 4 City: Canton State: CT Zip: 06019 Phone: 860-413-2281 E-mail Address: Amanda.aarde�'=ate QUALIFIED FOOD OPERATOR E. YES Z NO ❑ NON-PROFIT Name: N/A—Class 2 Operation Certificate#: Date: ADDITIONAL INFORMATION Water Supply: YES NO Wastewater Disposal YES ❑ NO FJechical: YES { NO If other,please explain: MENU "(PLEASE i --,Li r i E N u i T E?� IN AS MUCH DETAIL AS POSSIBLE)* Ben&Jerry's Prepackaged bulk ice cream;(Scooped:Cups,Sugar Cones,Waffle Cones,Sundaes),Prepackaged Novelties,bottled beverage ****PLEASE DRAW A DETAIL DIAGRAM OF FOOD BOOTH ON THE BACK OF THIS FORM. USING THE GRAPH PICTURE ON THE BACK OF THIS APPLICATION**** The food preparation and storage areas must be covered if event is outdoors. Be sure that the tents used for overhead cover are fire-rated, per the South Windsor Fire Marshal's office. AGREEMENT AND SIGNATURE By submitting this appikation,I affirm that the facts set forth in it are hue and complete.I understand that any false stailiements or other misrepresentations made on this application may result in immediate shutdown or revocation of my temporary Food Service License for the Town of South Windsor. Temporary Food Service License will be sued after the Food Inspector has comply his/her inspection. Applicant Name a (Please Print): Applicant Signature: Date: 05/22/18 � (0z01 `l � 'lz�'9 w's n=c' Town of South Windsor Health Department Temporary Food Event Questionnaire Form Please complete all questions and return to the Health Department with your application. 1. What is the source of the food to be served/dispensed? (Please include name/address of source) Foods must be from an approved source. Meat and dairy products must come from a government-inspected source. If it is necessary to bring in foods that are prepared at a licensed facility other than the temporary site,you must indicate how the food is protected during transport and how it is kept hot or cold as needed. Transported in Nelson Dip Case from Scoop Shop in Canton,CT where we get our deliveries. 2. How will the food items be kept cold/frozen? Ice must be from an approved potable source. Frozen foods cannot be thawed at room temperature. Proper thawing can be done in a refrigerator, under cool running water,or as part of the cooking process. All Ice Cream kept at servable temperature in cold plated Nelson Dip Case 3. How will the food items be cooked and/or hot held? A sanitized metal stemmed,calibrated probe thermometer to monitor food temperature is required. If thin patties are being cooked,a thermocouple may be needed to accurately check temperatures. N/A—All items are frozen 4L Please descn"be the type of hand washing facility to be used. There is a hand washing area at tent location, Hand wash bin includes:extra soap,extra paper towels&gloves Additiona`• information ❑ Contact the local Fire Marshal(86U-282-0669)to ensure compliance with the Fire Code. ❑ The food preparation and storage areas must be covered if event is outdoors. Be sure that the tents used for overhead cover are fire-rated, per the South Windsor Fire Marshal's office. ❑ Wastewater must be disposed of in a sanitary sewer or other approved sewage disposal system. ❑ Equipment and tables must be clean, smooth, washable, durable, non-absorbent and in good repair. ❑ Dust must be controlled (i.e. dry fields)by watering down. ❑ All workers at the food booth must sign a log sheet indicating the date,their name,address and telephone number and the hours that they worked. Please retain the log sheet after the event. ❑ If gloves are used,they must be a food grade quality glove and must be used for only one task (such as working with ready-to-eat foods or with raw animal food). You must wash your hands after removing the gloves and prior to putting on a new pair of gloves. Gloves must be discarded when damaged or soiled,or when interruptions to use occur. ❑ Food employees may not wear nail polish or artificial nails unless wearing intact gloves in good repair. HANDWASHING STATION FOR TEMPORARY FOOD BOOTHS Warm 1 water paper towels garbage free can flowing spigot astewate container A handwash station must be provided in or next to each booth to be used by food handlers. The station must have the following: 1) Insulated container with warm water and a spigot for hands fuse washing 2) A catch bucket that is larger than the supply container 3) Pump soap dispenser 4) 4) Paper towels I b X 10 13 rancu d, T-eh�-- gac kdroe O Sids� s��ts aria l yi��! C�aCk hard v�rashStafion wrt h co:i tvq s�n (�actl[nP arm - product kSpckU- - QXtycL�u�pt� U a cloS�d d p ablQ-) (charq